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T-185 with Ortho Plan
Our Access plan offers the flexibility of one premium rate and immediate
access to in-or-out-of-network benefits for all employees. Members are not
required to fulfill a deductible or pre-authorize any care. Additional plan
features are:
 | Freedom to choose any dentist |
| Fixed member in-network co-payments |
| Scheduled reimbursement for out-of-network
dental services |
Office Visit Co-Pay :
$10.00
Applies only when Preventive and Diagnostic procedures are performed
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In-Network
Patient Pays |
Out-of-Network
Maximum
Reimbursement* |
| Periodic Oral Exam |
No charge |
$24.00 |
X-Rays
(Bitewing - four films) |
No charge |
$27.00 |
| Panoramic Film |
No charge |
$50.00 |
| Semi-Annual Cleaning, Adult |
No charge |
$45.00 |
| Semi-Annual Cleaning,
Child |
No charge |
$30.00 |
| Sealant - per tooth |
No charge |
$23.00 |
| Fluoride - child only |
No charge |
$35.00 |
| Two surface silver filling, primary |
$18.00 |
$52.00 |
| Two surface white filling, anterior |
$23.00 |
$52.00 |
| Steel Crown |
$90.00 |
$19.00 |
| Porcelain crown (noble) |
$354.00 |
$136.00 |
| Pulp Cap |
$9.00 |
$23.00 |
| Scaling & Root Planing |
$33.00 |
$79.00 |
| Root canal therapy -
Bicuspid |
$114.00 |
$289.00 |
| Complete upper dentures |
$472.00 |
$132.00 |
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Orthodontics |
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| Treatment for children
up to 19 years of age |
| Evaluation |
$35.00 |
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| Treatment Planning |
$250.00 |
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| Orthodontic
Treatment |
$2,300.00 |
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| Treatment
for adults 19 years of age and over |
| Evaluation |
$35.00 |
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| Treatment Planning |
$250.00 |
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| Orthodontic
Treatment |
$2,500.00 |
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| Retention |
$450.00 |
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Annual Maximum Benefit
per Family Member |
$1,000.00 |
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*The Out-of-Network maximum reimbursement amount may
vary for Type I procedures based on the Preventive and Diagnostic office
visit copayment amount applied towards the cost of services rendered.
This schedule shows only a few of the covered procedures. Please see your
Benefit Administrator for a complete schedule. This schedule is intended
for comparison purposes only. The benefits for each plan will be
determined by the contract. This plan contains certain exclusions and
limitations. For a complete listing of benefits and exclusions and
limitations, please reference your certificate of coverage.
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